A. Problem Analysis

1. What was the problem before the implementation of the initiative?

Kutch, the largest administered district of the country with an area of 45,674 Sq.Km, which is bigger than even countries like Switzerland, Belgium, Denmark, Estonia etc. faced serious issues in the delivery of public health services in general and for vulnerable groups such as women and children in particular. The higher incidences of malnourishment among children and maternal mortality rate significantly higher than state average were the most pressing issues facing District Panchayat responsible for delivery of health and nutrition to expecting and lactating mothers. The cases of moderate and severe malnourishment stood at about 40% whereas maternal deaths stood at 42 in the year 2011-12. The geographical spread of the district along with its unique mix of different ethnicity resulted in diversity of challenges. Further the spatial spread of issues such as 33% of the maternal deaths occurring in just 5 primary health centres gave a local angle to the problem. The lack of education and extremely rigid social customs resulted in women marrying at a young age and lack of family planning measures causing them to deliver multiple children further aggravated the problem. The inaccessibility of the areas along with lack of agency to women was the biggest handicap District Panchayat faced.
This mix of inhospitable terrain and diversity meant that the problem has to be attempted afresh. The application of old methods will not work and thus District Development Officer Mr. Harshad Patel (IAS) decided to design an innovative solution for the problem affecting the district. The single biggest problem was to come up with a new model to deliver the health and nutritional services to women and children. The issue of lack of will and absence of motivation amongst the employees responsible for actual delivery of services was a big challenge for DDO Mr. Patel. Both these issues demanded great public attention for future progress of any country is dependent on healthy mother and healthy children. The lack of nutrition in formative years is scientifically proven to be disastrous for a growing child and this lack of early nutrition cannot be compensated at later age. This issue faced a majority of population and almost all social groups were affected by it.

B. Strategic Approach

2. What was the solution?

The initiatives aimed at creating participatory solutions for reducing malnutrition and improve maternal mortality rates. The initiatives were built on expert opinion of subject matter specialists and implemented by innovative deployment of available resources.

3. How did the initiative solve the problem and improve people’s lives?

SHAISHAV- The initiative for ensuring a healthy child was conceived to reduce the instances of malnourishment amongst children using Anganwadi facilities (Integrated Child Development Scheme Centers). The lack of coordination between health and ICDS department was the starting point of the strategy adopted to remedy malnutrition. The lack of understanding amongst many anganwadi workers regarding consequences of malnutrition was to be targeted as well. The beginning point was based on understanding that what cannot be measured cannot be done. Thus the first step was to measure the existing state of malnutrition amongst children. The physical infrastructure needed (weighing scales, measuring tapes, growth charts) for the same was ensured at every centre followed by detailed examination of every single child resulting in a significant higher number of malnourished children as severe underreporting missed these children earlier. This baseline gave an idea about the extent of malnutrition prevalent in the district. The next step was to train and sensitize anganwadi workers (AW) by organizing training camps with assistance from UNICEF and other NGOs. The detailed meetings, reviews, wide publicity and involving government servants and private entities in this movement made the initiative result oriented. The adoption of children’s and anganwadis by officers and private entities brought focus and accountability in the working of AWs and thus ensured that children receive adequate nourishment in the anganwadi centres. The result was an astonishing improvement from 40% malnourishment in Jan 2012 to 21% in December 2012. The largest beneficiaries of this initiative were children’s from poor and marginalized backgrounds.
MATRURAKSHA- The stated objective of the initiative was to check the higher maternal mortality rate prevalent in the district (160 compared to state average of 148). The initiative resulted in putting safe and healthy child birth at the top agenda of health authorities. The lack of prioritization and subsequent lack of attention has caused 42 maternal deaths in the year 2011-12. The strategy adopted focused on clear identification of target audience and then continuous follow up to ensure that these women undergo all routine checkups, use health facilities for delivering the child, and any complication is identified before hand and high risk mothers are given special care. The coordination of health workers with elected representatives’, ICDS workers and involvement of community at large was the peg on which the initiative was built. The training of all health workers by master trainers followed by intensive IEC activity to ensure that all expecting mothers are brought under the fold resulted in bringing a sea change in the situation. The capacity building of the health professionals was motivating for them to achieve results. The localization of solution wherein 5 PHCs accounted for a third of maternal deaths ensured that such kind of special areas gets required attention to check MMR. This concentration of deaths in few PHCs was a revelation in customizing solutions for different areas as the geographical spread of Kutch is huge and so is the ethnic diversity. The help of subject matter specialist in dealing with causes of deaths ensured that the solutions designed do work on ground. This resulted in bringing great sense of relief for women as maternal deaths reduced to 29 from 42 in one year.

C. Execution and Implementation

4. In which ways is the initiative creative and innovative?

The biggest innovation that the DDO did was to ensure that the initiative does not remain simply a departmental object. The involvement of private sector, community and elected representatives in the IEC phase and implementation phase gave the uniqueness to the initiatives. The result was that a health and ICDS issue was seen from a new light of a social issue. This new definition meant that the solution too would be grounded in society rather than one department. The ability to transform a department agenda to social agenda using persuasion and leadership made the initiative successful. The clean slate approach where all measurements were done afresh brought the real picture and thus helped to formulate new solutions. This newness in definition of problem and then devising innovative arrangements such as public private arrangements, adoption of anganwadis and malnourished children by senior government officers, personal monitoring of all maternal death cases and wide publicity to those involved in unscrupulous healthcare practices thereby cautioning unsuspecting villagers lent the success to the initiatives.

5. Who implemented the initiative and what is the size of the population affected by this initiative?

District Development Officer (DDO) Mr. Harshadkumar Patel [IAS] was the chief architect of the initiatives. Being the administrative head of the District Panchayat, DDO Mr. Patel envisioned the initiatives, gave direction to the efforts, monitored the implementation personally and ensured that outcomes act as a feedback for continuous refinement of the projects. The initiative involved different departments of the district panchayat such as ICDS, Health department, Education department, District Rural Development agency. The overall design, implementation, monitoring and evaluation were done by the office of the DDO. The DDO also ensured active participation of the private individuals and institution, experts, advocacy groups and international agencies such as UNICEF, NGOs amongst others in various stages such as adoption of anganwadis, training of staff, evaluation methods etc. Later on Mr.Harshad Patel in the capacity of the District Collector kept on flowing up and coordinating with various departments through mechanisms of sankalan, SWAGAT and other forums to help institutionalize the initiatives.
Being a large district and undergoing rapid industrialization Kutch has a burgeoning population and thus a large number of children. The initiative targeted over 100,000 children in the entire district. The extent of success could be understood from the massive drop in number of moderately malnourished Children in the age group of 0 to 6 years from 37.31 to 20.33 percent and severely malnourished children from 1.95 to 0.77 percent within a year. The initiative aimed at safe motherhood had all expecting mothers in the district as its target audience. The significantly higher MMR could be checked within a year and the initiative brought drastic reduction in the maternal mortality rate by reducing deaths from a high of 42 to 28 within a year.

6. How was the strategy implemented and what resources were mobilized?

The approach involved creating an environment where all stakeholders could have a sense of ownership while implementing the initiative and see the big picture rather than getting trapped in their narrow departmental visions. This focus on involvement of all ensured that the team can have members having complementary skills and thus add to the strength. This channelization of energy from all the sources was the guiding mantra for the initiative.
The focus on involvement helped solve the biggest problem of qualified human resources. The lack of proper training to anganwadi workers was remedied by a well designed training of trainers through UNICEF and NGOs working in health sector. The utilization of different department officials for adoption of severely malnourished children and anganwadis brought additional qualified human resources.
The supplementary nutrition kit (Shaishav Kits) comprised of sprouted grams(500gms), besan laddus(300gms), dates(500gms), groundnut and sesame chikki (750) and bournvita (200gms) costing around Rupees 250(4$). This expense was borne by involving private donors, utilizing funds received from big corporations under their Corporate social Responsibility (CSR) charters. This was all managed by mobilizing financial resources over and above the routine government grants.
The reduction in maternal mortality rates could only be achieved if technical competence of Gynecologists and Obstetricians could be shared with doctors and midwives and other health staff working at the level of the PHC. This was achieved through various training camps where large scale dissemination about issues arising during child birth were explained in detail by the senior OBG professionals along with explanation of methods for early identification of high risk mothers. The personal explanation by concerned MO for every case of maternal death brought in a regime of enhanced accountability and thus warranted personal attention by MO during and before child birth. This change in oversight mechanism resulted in bringing in the right amount of seriousness required by professionals involved in the last mile service delivery.

7. Who were the stakeholders involved in the design of the initiative and in its implementation?

District Panchayat Kutch like all elected bodies works with a state government appointed administrative head as District Development Officer who is a senior time scale IAS officer and an elected President along with other elected representatives forming various committees. The DDO is assisted by senior officers of the district Panchayat from health, education, ICDS, agriculture, engineering, accounts, and finance divisions. The most important contribution is of the DDO for he is the one responsible for the overall planning, coordination and thus takes all responsibility and overall ownership of all the initiatives whether successful or not.
Mr. Harshadkumar Patel (IAS) was the DDO under whose leadership the District Panchayat Kutch could envision an initiative focusing on improving maternal and children health. The leadership style of Mr. Patel contributed immensely to the success of all the initiatives for he could foresee the potential bottlenecks and thus act in time to save the projects from emerging challenges. The DDO would plan in detail and come up with innovative participatory models such as adoption of anganwadis, adoption of malnourished children, raising finances using the social capital and tapping into private resources available in the form of CSR and PPP. The other officials of the district panchayat particularly from health, ICDS and education department contributed significantly in reaching out to actual beneficiaries. The corporate foundations such as Adani Foundation, global bodies such as UNICEF, and other NGOs helped with man, material and money. The anganwadi workers, ASHAs, ANMs who dedicated themselves fully to the DDOs vision were able to measure the correct extent of malnutrition and then work meticulously along with clear documentation of all the children falling under malnourished category continuously over the years. This along with proactive participation from village elders, community leaders and elected representatives further improved the implementation.

8. What were the most successful outputs and why was the initiative effective?

The thrust of DDO from beginning was on advancing the districts journey towards SDGs. The various outcomes achieved due to the implementation of the initiatives bear testimony to the success in advancing the journey of around 100,000 children and thousands of expecting mothers towards a world which is sustainable, inclusive and equitable.
• SHAISHAV: An all round nutrition drive for anganwadi children ensured that instances of the severe and moderate malnourishment drops nearly by an amount of 50%. The moderately malnourished children dropped to 20.33% from a high of 37.31%. The severe malnourishment figure too came crashing down to a mere .77% compared to 1.95%. The initiative set an example for ensuring good health and well-being.(SDG 3)
• MATRURAKSHA: A holistic initiative to check maternal mortality brought in gender equality discourse in the mainstream of the district panchayat functioning. The initiative brought in expert guidance and help to the medical officers posted in the remotest location of the country. The involvement of the community and health care officials reduced maternal deaths significantly. The initiative brought down the number of maternal deaths from a high of 42 to 29 in the entire district within a year.
• Kutch became the model for grading of all anganwadis based on their performance related to malnourishment. The anganwadi grading helped clearly delineate the problems emerging in particular localities. The holistic grading of the centres through questionnaire and physical visit resulted in creating a sense of competition amongst anganwadis to outperform amongst themselves.
• The starting afresh and ensuring that all children are screened for identifying state of malnutrition prevalent in the entire district again became a template for implementing large scale social sector project in the state. The clean slate approach used became a model for correct assessment and then applying solution. Further this gave all families a sense of equality and brought confidence in government.The creation of color coded cards and registers at all anganwadis for documenting the growth story of the children over years brought in an inbuilt check over fudging o f data by lower level functionaries.
• The adoption of severely malnourished children by different departments ensured that dedicated follow up of these children and thus reduced the time needed for them to come out from severe malnourishment. A total of 2252 children were adopted by 13 government departments along with 328 children adopted by the community.

9. What were the main obstacles encountered and how were they overcome?

The main challenges encountered during implementation were on three fronts of traditions, geography, and motivation. The embedded nature of traditional customs and communities resistance to change was a big challenge in the outreach to expecting mothers. The prevalence of purdah, birth at home and rigid customs prevented many women to come out from house and thus kept them away the health facilities. This was overcome by a focused long term IEC program wherein a total of 85 camps, 400 meetings and 180 interactions of the parents along with ICDS and health functionaries were conducted. This intensive outreach program was built on carefully garnered support of elected representatives and community leaders to reach out to ever reluctant women due to ethnic reasons.
The geography severely limited the district panchayat option in reaching out to the women situated in the remotest corner. The complexities developed during the child birth needs tertiary health care facilities to deal with those but the wide geography means that the time required for the help to reach was long enough to be of no use. To overcome the strategy adopted was early identification of high risk mothers and then follow up with them continuously and during the EDD ensure that proper medical help of the highest possible quality is nearby.
The lack of effort made earlier to improve MMR and check malnourishment on a pan district level limited the vision of the officials. This lack of confidence in the ability to overcome these big challenges lay at the core of poor result orientation. The DDO through training camps, group exercises, training of master trainers could help build that belief that it is possible to bring significant improvements. This belief when translated into the work did wonders for the Kutch.

D. Impact and Sustainability

10. What were the key benefits resulting from this initiative?

The single biggest benefit resulting from the implementation of the initiative was the massive drop in the levels of the malnourishment amongst children. The anganwadi going children usually belongs to the most poor and vulnerable sections of the society. Thus there need for supplementary nutrition is highest. The fact that existing model was unable to ensure sufficient nutritional support was visible in significantly higher levels of the malnutrition prevalent amongst anganwadi children. The nutrition drive for anganwadi children ensured that instances of the severe and moderate malnourishment drops nearly by an amount of 50%. The moderately malnourished children dropped to 20.33% from a high of 37.31% at the beginning of the initiative. The severe malnourishment figure too came crashing down to a mere .77% compared to 1.95% at the beginning of the year.
Also the initiative was able to involve the entire community. This ability of the initiative to have society a part of the implementation ensured that the accountability measures are strong. The openness and visibility of the drive ensured community involvement which further ensured concurrent social audit. This further improved outcomes as feedback could be put in to use regularly and shortcomings could be taken care of in real time.
The initiative for safe motherhood MATRURAKSHA is a stellar example of gender consciousness at work in the functioning of district panchayat. Ensuring safe motherhood generates positive externalities such as healthy child, generation of human capital, no loss of opportunity cost et.al. The drive used clear identification of dark spots. The five PHCs where 16 maternal deaths occurred in previous year were identified. This identification in turn helped to focus on issues better. The geographical remoteness and social backwardness of these 5 areas was the primary reason for such high rates of maternal deaths. The initiative took note of that and was designed in a way to involve local community leaders along with expert health care professionals to personally monitor these PHCs which resulted in checking maternal deaths there. This mainstreaming of most vulnerable section made the drive not only gender sensitive but socially inclusive as well. The impact was measured using the data available from the departments responsible for delivery of these services. The ICDS officials are involved in measuring the prevalence of malnutrition. The available figures before the initiative and after the initiative were compared to see the real improvement in the figures. The same methodology was followed using the statistics of health department for assessing the fall in maternal mortality rates. The baseline at the beginning of the intervention was compared with figures at the end of the year which clearly brought out the improved picture. The measurement were documented and maintained at the level of individual ICDS centre and PHC and thus were available for public scrutiny. This transparency in turn improved public confidence in the robustness of the results being shared by the district panchayat.

11. Did the initiative improve integrity and/or accountability in public service? (If applicable)

The initiatives through its multiple stakeholder involvement and inbuilt transparency in the documentation resulted in large scale involvement of elected representatives, community leaders and NGOs. This ushered in an era of open governance in the activities of the departments undertaking these initiatives. This transparency promoted accountability which is the bedrock on which integrity is built. Thus the initiative through its carefully designed approach using public gaze as a tool of concurrent audit improved the integrity of the officials involved in delivery of public health services. The registers showing growth details of the children were made public documents and were available for inspection at all ICDS centers. This reduced the propensity to fudge data reduced and true picture regarding nutritional status was put up before authorities and public. This made it easier for parents to hold government department accountable for any lapses in the functioning.
Similarly the detailed documentation of all expecting mothers with focus on high risk mothers and involvement of community leaders along with detailed dissemination using all available media forums gave widespread publicity to the projects underway which in turn brought the public gaze. The active involvement of public brought the required level of accountability.

12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)

The initiative to check malnutrition and reduce maternal deaths concerned directly the poor & women as the biggest beneficiary of ICDS are children from poor communities and women using government health facilities too comes from the less privileged background. The ICDS department structure is such that in charge of all anganwadi centers are women known as anaganwadi workers (AW). Also the villages have a female health functionary by the name of ASHA(Accredited Social Health Activist) who is the first point of contact for all villagers in general and expecting mothers to the health care infrastructure. This design ensures that women are comfortable in their interaction. Since the ASHA is a local functionary the familiarity with her adds to the comfort level. The AW were trained and sensitized through UNICEF organized workshops to help understand child psychology better and be considerate towards the needs of vulnerable section of the society. These exercises improved emotional intelligence of the functionaries. This realization that there voice is heard reached the entire community through word of mouth thereby improving the reach. The poorest and most vulnerable were made the brand ambassadors for the initiatives which contributed to its success and making the drive inclusive.